ED Accreditation Update

Preparation can lead to good survey results

Just because surveys by The Joint Commission are no longer announced, it doesn't mean you can't prepare for them, say ED experts.

"It is optimal to integrate aspects of The Joint Commission regulations into departmental daily and shift rounds," advises Diana Contino, RN, MBA, FAEN, senior manager with Costa Mesa, CA-based BearingPoint, which provides management and technology consulting services. "Teach the charge nurses, clinical managers, and some of the key staff to survey your ED and other areas on a regular basis," she advises.

At St. Jude's Medical Center in Fullerton, CA, "for each of the different areas of standards for environment of care, one person in leadership in our department is responsible for a binder that has all our background information to support all of the different standards," says Vicki Sweet, RN, director of emergency services. "Prior to our code JUDE [Joint Commission Unannounced Disruption Event] drills, [we use these forms] to make sure [the ED leaders] are updated."

Contino adds these other tips:

  • SBAR (Situation-Background-Assessment-Recommendation), "board rounds," and team change-of-shift reports at the bedside are all ways that improve the effectiveness of communication and involve patients in their care.

Board rounds, Contino explains, usually involve the ED physician, nurses, techs, and registrars, who review what the patients need, what is pending, and what the staff can do to expedite care. They enhance team coordination and communication, she notes.

Change-of-shift reports, Contino says, are conducted at the bedside and involve the nurse, the physician and the patient. "Some off-going physicians introduce the patient to the oncoming physician and review what has been done, what is pending, or what needs to be done, and at that time they give the patient and family the opportunity to ask questions," she says. "This is a big patient satisfier and helps to improve safety and quality."

Having charge nurses, ED staff and staff from other departments trained in observation and the Joint Commission requirements is beneficial for ongoing preparedness.

  • Improvement in the accuracy of patient identification can be assessed through unit rounds and accuracy performance metrics — the routine measurement and reporting of errors, delays, omissions, or near misses, putting particular emphasis on improving processes to reduce errors. Use registration accuracy programs, which are setting up a mechanism to check the accuracy of the key elements of the registration process. For example, is the address correct? Was a Medicare conditions of participation form signed? Registration accuracy programs combined with assessments and observation of how staff members are identifying patients help departmental improvement teams identify performance gaps.
  • Charge nurses can do unit rounds assessing patients and their risk for falls or pressure ulcers. As they conduct these rounds, they increase discussions and staff awareness, and they actively identify solutions to increase patient safety on a shift-by-shift basis.